Junior Claims Assessor

The Junior Claims Assessor will have the responsibility of ensuring that medical claims and cases are vetted and that they meet the set objectives for a given project. The position will also involve giving detailed reporting on all the general findings from the claims or cases vetted with the aim of improving project outcomes as well as enhancing system functionality.

KEY DUTIES AND RESPONSIBILITIES:

• Verify and analyze all data on claims or cases and ensure these meet the project objectives as well as payer expectations for the various projects.
• To send back simple yet detailed feedback to the provider team where claims do not meet the project expectations.
• To ensure any general trends or inconsistencies noted are reported to the operations and provider teams.
• Timely assessment of claims re-submitted by the providers, ensuring the queries raised are understood, and following up with the provider team to ensure they are resolved.
• Provide support to the customer call center to address medical queries that have been escalated to CarePay.
• Document and be able to extract, present, or discuss provider practices or disease trends.
• Deliver feedback and training aimed at addressing the trends picked from the claims assessment exercise.
• Mapping generic rules to medical services, procedures, drugs and lab tests.
• Participate in testing and documentation of selected CarePay systems.
• Perform all other duties as assigned by the supervisor.

EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:

• Degree/ Diploma in Clinical Medicine or Nursing
• Good understanding of private and public healthcare delivery.
• Have a strong understanding of medical treatment protocols and cost-effective prescribing habits in relation to market segmentation.
• At least 2 years’ experience in a busy hospital set-up
•  Experience in insurance will be an added advantage.